Dermatology in the NHS: last 70 years - Sriramulu Tharakaram MD FRCPIreland FRCPLondon

Dermatology as a speciality has made tremendous strides over the past 70 years of the NHS. Once skin diseases were regarded as chronic and hardly treatable but this has changed with advances in dermatology. Today Dermatology has evolved into so many subspecialities including to name some paediatric dermatology, dermatological surgery and lasers, dermatological oncology, contact dermatitis, photobiology, epidermolysis bullosa pioneered in the UK by late Prof Robin Eedy and succeeded ably by Prof John McGrath and Prof Mellerio and and there maybe one or more dermatologists looking after skin rashes in haemato-oncology settings. Powerful drugs are used to treat cancers once untreatably fatal and these produce skin rashes needing dermatology input. Not to forget the research dermatologists making new strides and bringing the products of their effort from the laboratory benches to the patient’s bedside. Whilst all these advances are going ahead Dermatology is also under attack by new changes in the NHS pushing it out of the hospital into the community leaving the in-patients with rashes in a state of limbo; the bidding system also leaving the speciality open for grabs by market forces whose primary objective is monetary under the guise of providing a more efficient service. Some such services have collapsed leaving patients back to where they started!

In England the largest Dermatology service is the one coming under the St John’s Dermatology Centre, once an independent hospital but now under Guy’s King’s St Thomas’s NHS Trust. Large services exist in Leeds, Birmingham, Newcastle, Manchester and in Cardiff, Edinburgh, Glasgow, Dundee to mention a few.

Whilst the backbone of Dermatological treatments are topical creams and ointments since 1951 when Dr Sulzberger in the USA discovered hydrocortisone, which evolved into more potent fluorinated steroids, Dermatology on both sides of the Atlantic started using drugs used in cancer in low doses to control skin disease as psoriasis with remarkable benefits. Dr Harvey Baker from the London Hospital was one such pioneer. The same Whitechapel hospital carries out breath taking research in molecular dermatology. There are a whole plethora of drugs in Dermatology: acne treated early can leave the patient with virtually normal skin; immunomodulator creams as tacrolimus and pimecrolimus for eczema reduce the fear of skin damage to steroids; psoriasis covering the whole body can be controlled effectively where light and topical treatments seems less effective with the expanding armamentarium of a new class of drugs: Biologics. Crippling rheumatoid arthritis and psoriatic arthritis may soon become a thing of the past.

Dermatologists once regarded themselves as physicians quickly absorbed the American enthusiasmfor surgery and in particular Moh’s surgery invented by Dr Fredrerick Moh from Wisconsin; the procedure where skin cancers are removed under microscopic control virtually guaranteeing full and just enough removal of a skin cancer in strategic parts of the face as eyelids and nose. Dermatologists specialising in Moh’s surgery are always in great demand. A range of treatments exist for skin cancers depending on the type: a cream as 5 Fluorouracil, Aldara, Photodynamic therapy, surgery, radiotherapy and chemotherapy. More importantly the 2 week rule allows GP’s to refer patients who must be seen within 2 weeks for skin cancers with a potential to spread and the regular MultiDisciplinary skin cancer meeting assuring quality control of such skin cancers across the board. The patient gets all this in the tax payer funded NHS without touching his or her purse or worrying about costs.

The history of dermatology in the NHS was recounted in an article written 10 years ago. Some remarkable changes that have occurred are recounted herein.Infantile Haemangiomas or vascular birthmarks are more common in the white population occurring in 4-10% of infants. They grow rapidly over the first 3-12 months and then spontaneously involute. Treatment is seldom needed unless it ulcerates or causes functional impairment. Treatments were large doses of steroids with a multitude of side effects. UNTIL in 2008 in France Propranolol given to treat a cardiopulmonary condition in an infant with haemangioma resulted in amazing improvement of the haemangioma (Ref: N Eng J Med June 2008): this is now adopted as a first line treatment.

Biologics

These are innovative new therapies engineered to block certain molecular steps that are crucial in the pathogenesis of disease. They have revolutioned the treatment of psoriasis and are used in various other diseases as eczema, urticaria and vasculitis.

Psoriasis: Research into pathogenesis of psoriasis has identified mechanisms of blocking the likely causative pathways. These drugs are referred to as Biologics and include Adalumimab, Etanercept, Infliximab, Ustekinumab, Secukinumab, Ixekinumab. With such treatments it is possible to achieve disease free “clear skin” something which was impossible before. Sometimes these treatments do not work and all such data is pooled by the British Association of Dermatologists Biologics Interventions Register (BADBIR). These are expensive drugs and have to be approved by NICE and there is a vetting process in prescribing them. As patents on these drugs expire drug companies are making slightly cheaper copies or Biosimilars with a modest 10% cost reduction.

Eczema: A proportion of eczema patients do not respond to creams and ointments: these patients are treated with systemic treatments as methotrexate. Sometimes even these do not work. But there is new hope with a biologic Dupilumumab.

Urticaria: Chronic Urticaria or “hives” can sometimes make the affected patients ill and unresponsive to antihistamine and systemic treatments .IgG atoantibodies against IgE were first identified in St John’s Dermatology Centre. A biologic Omaluzimab given subcutaneously to such patients gives them great relief.

Likewise there is hope for autoimmune blistering disorders with Rituximab when all else fails. Lately Alopecia areata (bald patches to total hair loss) and Vitiligo, both autoimmune conditions had few effective treatments can hope for the better with a new category of drugs Janus Kinase inhibitors Tofacitinib, Baricitinib and Ruxolitinib. Vitiligo in the Indian subcontinent is stigmatized as Leprosy adding to the patient’s woes: this treatment not yet available universally may hopefully help immensely.

Melanoma: Melanoma is the most fatal common skin cancer, the fifth most common and the fastest rising cancer in the UK. Whilst excision remains the gold standard some melanomas spread to internal organs. Knowledge of Oncogenes and BRAF has resulted in drugs that inhibit BRAF: vemurafenib/Dabrafenib. Looking at immunogenicity and melanoma newer drugs as Ipilimumab and Nivolumimab also referred to as check point inhibitors help to clear metastases when given which is a stunningly remarkable advance.

Nurses and GP’s in Dermatology Nurses have always played an important role in the development of this speciality. Given the shortage of dermatology consultants nurses have stepped as nurse specialists and nurse consultants working alongside consultants and helping to ease the pressures by contributing a much needed and valued role. GP’s have developed a special interest in dermatology and where well trained are of great help.

Secretaries

With the immense administration needs in the NHS secretaries who do so much are often taken little note of. In DGH settings they often function like a specialist registrar and if you have a good secretary then value them greatly and you will get rich dividends.

Whither Dermatology?

Dermatology like all things is undergoing phenomenal changes; whilst there are great advances happening scientifically these have to be delivered with costs in mind. Perhaps a more integrated and shared service with dermatologists working in hospitals and communities and a nice exchange between teaching and district hospitals enhancing standards overall might help. Whatever advances maybe achieved the patient should be the central focus and the NHS certainly can take pride in quality care delivered free to all those who need.